Setting the Scene
The Deceased had a history of self-harm and suicidal attempts and was engaged with mental health services from an early age. Whilst serving a long-term prison sentence, the Deceased’s anti-depressant and anti-psychotic medication was reduced at the Deceased’s request and following an assessment of his state of mind at the time. However, there was no follow-up assessment or proper monitoring of the psychiatric management plan. He was not assessed face-to-face by a psychiatrist, despite informing the mental health nurse that he had thoughts of suicide. A few days later he self-harmed but there was still no psychiatrist face-to-face assessment and no escalation in the support or review of the medication in his possession. A few days later he took a fatal overdose of the medication.
The main learning points from this review stem from the following events:
Suboptimal support and assessment of the Deceased’s risk following self-harm, especially in light of the totality of the information the MH nursing staff had due to previous suicide/self-harm talks.
Reducing the Deceased’s medication on the advice of a psychiatrist who had not reviewed or met the Deceased, and not monitoring the Deceased’s mental state sufficiently thereafter.
- Despite the Deceased’s continuing threat of suicide, they continued to prescribe in-possession medication without any mental health review, which is what ultimately assisted his suicide.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
Diagnosis of mental health conditions is never black and white. Due to varying factors which include the prison culture, staff shortages and lack of understanding, this is inherently difficult. But TMLEP have identified some key measures which can be used to prevent recurrence of this sort of incident, namely:
Prisons should ensure that they have a clear and consistent process for prison staff to refer vulnerable prisoners directly to the mental health team, and that both prison and healthcare staff have a shared understanding of this process and how to make urgent referrals when necessary.
Patients with a complex history of mental health, such as the Deceased, should have a face-to-face assessment with a Psychiatrist after any decision has been made to reduce the medication, preferably within 2 weeks. This is not only a safety net for the decision making, but also gives healthcare providers the opportunity to re-consider the appropriateness of ‘in-possession’ medication. It is essential to have clear guidelines on the best practice for the selection and use of existing validated assessment tools within a prison setting.
Protocols or Standard Operating Procedures for clinical decision-making should be in place to cover all aspects of healthcare. This should include one for the assessment of in-possession medication in a prison setting.
Regular multidisciplinary meetings of healthcare staff should be held, ideally daily, so that information about safeguarding the patients at risk can be shared to all members of the clinical team.
Mental health is a complex issue. In order to determine the optimal care and support needed, it is recommended that community GPs provide comprehensive details of a prisoner’s health records to the prison healthcare team, so that there is a complete understanding of a prisoner’s mental health.
There needs to be an improvement in mental health awareness. The primary issue identified in this matter was a lack of mental health awareness and training. Despite SASH (Suicide and Self Harm awareness) training already being available, it should be mandatory for all prison officers and healthcare staff to provide them with necessary guidance for the identification of signs of mental illness and vulnerability.
- Whilst ACCT is a recognised and renowned program, ACCT has been criticised for needing improvements, such as the requirement for prison staff to have frequent refresher training, training focussed on mental health and guidance on how to adapt the ACCT process to meet individual prisoner needs.
Mental health is a complex issue. Suicide is the single most common cause of death in correctional settings. The challenge for suicide prevention is to identify those people who are most vulnerable and intervene effectively. The key means to prevent suicides in prisons is through adequate monitoring, communication and the provision of accessible mental health care and suitable treatments. All prison residents with mental health disorders who present a serious suicide risk should be closely monitored. When medication is reduced, safety nets need to be in place to ensure opportunities to obtain lethal methods of self-harm are removed. This case study shows that whilst the care did not contribute to the Deceased’s mental state, it did allow the Deceased to be in possession of materials that were used to end his life.